I give my permission to Alexandra Hernandez, DDS, to perform all necessary procedures. In the event that I need treatment, Dr.Alexandra and/or staff will inform of the different methods of treatment. I understand that there is no guarantee of success or permanence to the treatment. If I have any questions regarding treatment, procedures, or insurance, it is my responsibility to make sure my questions have been answered by Dental Haven or my insurance company prior to signing the proposed treatment plan consent form. I, therefore, understand the above statement and consent to the use of procedures if deemed necessary by Dr.Alexandra.
Dental Haven requests a parent or guardian present for all appointments to children under the age of 18. I understand that if I am not present at my child’s appointment, this may limit what is performed at the appointment.

The patient or guardian is responsible for payment at time of service, unless prior arrangements have been approved.

PAYMENT POLICY

INSURANCE:

In most cases, insurance does not cover the full cost of services. It is designed to reduce your cost, but not to eliminate it completely.
Our staff will help you receive the maximum benefit available under your policy. However, please remember you are fully responsible for all fees charged by this
office regardless of insurance coverage.

We submit all claims to your insurance company after each appointment. The balance that is not covered by insurance is due on the date of service. The following methods of payment are available:

**Cash or check

**Visa/Mastercard

**American Express

**Discover

**CareCredit

Should you need copies of dental records, there is a $4.00 processing fee for technician time, materials, and postage.
If ortho models need to be copied, the fee is $55.00.

Any cancellation without giving 24 hours notice or failure to keep the appointment will result in a charge of $55.00.

I have read and hereby agree that I am ultimately responsible for payment of this account.

General Dental Medical Hx

Name

Date

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body.
Health problems that you may have,or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.
Thank you for answering the following questions.

Are you under a physician's care now? if so, yes or no? for

Name of present physician and telephone number

Date of last medical exam

Have you ever been hospitallized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Do you have a history of mental illness?

Do you currently use tobacco? If so, what kind, amount, and for how long?

Do you have a history of tobacco use? If so, what kind and for how long? When did you quit?

Women: Are you...

Pergnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Other Allergies?

Do you currently use controlled substances?

Do you have a history of controlled substance use?

Do you have, or have your had, any of the following in the past 10 years? (Check all that apply)

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina (chest pains)

Arthritis/Gout

Arthificial Heart Valve

Artificial Joint(s)

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Cold Sores/Fever Blisters

Congenital Heart Disorder

Convulsions

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy Or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells/Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Glaucoma

Hay Fever

Heart Attack/Failure

Heart Murmur

Heart PaceMaker

Heart Trouble Disease

Steroid Use

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives/Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Parathyroid Disease

Psychiatric Care

Alcoholism

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors/Growths

Ulcers

Venereal Disease

Coronary By-Pass

Have you ever had any serious illness not listed? If yes,

Comments:

DENTAL HISTORY

DATE OF LAST DENTAL VISIT

WERE XRAYS TAKEN AT YOUR LAST APPOINTMENT?

DO YOU HAVE ANY CONCERNS OR COMPLAINTS ABOUT YOUR TEETH AND/OR GUMS AT THIS TIME?

ARE YOU HAPPY WITH YOUR SMILE AND THE APPEARANCE OF YOUR TEETH? YES/NO... IF NO

HAVE YOU EVER HAD AN UNFAVORABLE DENTAL EXPERIENCE? YES/NO... Check For Yes

ARE YOU APPRENHENSIVE ABOUT DENTAL WORK?

NO

SOMEWHAT

VERY

EXTREMELY

HAVE YOU EVER HAD ANY PROBLEMS GETTING NUMB FOR A DENTAL PROCEDURE? YES/NO... IF YES

HOW OFTEN DO YOU BRUSH YOUR TEETH?

HOW OFTEN DO YOU FLOSS YOUR TEETH?

DO YOU SUFFER FROM OR EXPERIENCE ANY OF THE FOLLOWING: (check all that apply)
Check All

LUMPS IN YOUR MOUTH

BLEEDING OR RECEDING GUMS

GRINDING OR CLENCHING

POPPING OR CLICKING OF JAW

DISCOLORED TEETH

CROWDED TEETH

SENSITIVE TEETH

SLEEP APNEA/CPAP MACHINE

To the best of my knowledge, the questions on these forms have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform that dental office of any changes in medical status.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain
rights to privacy regarding my protected health information. I understand that this information may be used for:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use or disclose your health information to obtain payment for services provided.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals,
evaluating practitioner and provider performance, conducting training programs,accreditation, certification, licensing or credentialing activities.
Your authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written
authorization to use your health information or disclose it to anyone for any purpose.If you give us an authorization, you may revoke it in
writing at any time. Your revocation will not affect use or disclosures permitted by your authorization while it was in effect.
Unless you give us written authorization,we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family & Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice.We may
disclose your health information to a family member, friend or other person to the extent necessary to healthcare or with payment for your
healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in notification of (including identifying or locating) a
family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If
you are present, prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or
disclosures.In the event of your incapacity or in emergency circumstances, we will disclose your health information based on a determination
using our professional judgment,disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We
will also use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in
allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of
abuse,neglect or domestic violence or the possible victims of other crimes. We may disclose your health information to the extent necessary to
avert a serious threat to your health or safety or the health or safety of others.
National Security: Under certain circumstances, we may disclose to military authorities the health information of Armed Forces personnel. We
may disclose to authorized federal officials any health information required for lawful intelligence, counterintelligence, and other national
security activities.We may disclose to correctional institutions or law enforcement officials having lawful, custody protected health information
of inmates or patients under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail
messages, postcards or letters).

________________________________________________________________________________________________________________________________________
Your signature below indicates that to the best of your knowledge, all information entered in the patient registration and medical history portion of this document is accurate and up to date.Your signature below indicates that you agree to our dental treatment and payment policies.Furthermore, your signature below indicates that you understand Dental Haven’s compliance with the federal HIPAA laws.If you’d like a full copy of HIPAA, please ask a member of the Dental Haven Staff.
________________________________________________________________________________________________________________________________________

Patient Name:

Signature:

DATE

Relationship to Patient (if Applicable):

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